Menstrual Cycle–Influenced Disorders

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Chapter 36 Menstrual Cycle–Influenced Disorders

The human menstrual cycle is unique as a physiologic process in that it involves mechanisms that change on a daily basis rather than remaining stable. This process of change is carried out through the many intricate hormonal interactions between the hypothalamic region of the brain, the pituitary gland, the ovaries, and to some extent, the adrenal glands and the pancreatic islets of Langerhans (see Chapter 4). To a large degree, the subject matter of reproductive endocrinology deals with disturbances of this interglandular hormonal communication that may result in irregular or absent menstrual cycles.

There is a second group of menstrual cycle–associated disorders, the hallmark of which is regular ovulatory cycles that cause dysfunction of other organ systems. In these menstrual-influenced disorders, the causative factors are not abnormal concentrations of the hormones of the hypothalamic-pituitary-ovarian (HPO) axis, but rather are atypical end-organ responses to normal levels of gonadotropins and sex steroids. A common feature of these disorders is the inability to distinguish between affected women and normal controls by measurement of the traditional HPO hormones. Interestingly, in many cases, relief from the symptoms of these disorders can be obtained by intentionally disrupting or abolishing regular menstrual function. The most typical menstrual cycle–influenced disorder is premenstrual syndrome, or PMS.

image Premenstrual Syndrome and Premenstrual Dysphoric Disorder

The acronyms PMS for premenstrual syndrome and PMDD for premenstrual dysphoric disorder refer to the same pathologic process at opposite ends of the symptom spectrum (Figure 36-1). In both PMS and PMDD, patients experience adverse physical, psychological, and behavioral symptoms during the luteal phase of the menstrual cycle. There is a crescendo of symptom intensity up to the time that menses begins, with quick resolution thereafter. Some patients have a brief surge of symptoms at the time of ovulation in midcycle.

As many as 80% of regularly ovulating women experience some degree of physical and psychological premenstrual symptomatology. Those who have mild to moderate symptoms are said to have PMS. In 5% or less of women, these symptoms are so severe that they seriously interfere with usual daily functioning or personal relationships. These women are characterized as having PMDD.

Common symptoms reported by patients include depressed mood, anxiety, affective lability and irritability, decreased interest in regular activity, difficulty concentrating, fatigue, change of appetite, sleep disturbance, and feelings of being overwhelmed. Physical symptoms include breast swelling and tenderness, bloating (a sense of abdominal swelling), weight gain, edema, and headache. The diagnosis of these disorders is confirmed by the predominant occurrence of symptoms in the luteal phase as documented on a menstrual calendar of two consecutive cycles.

A formal set of diagnostic criteria has been proposed in the fourth text revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association for PMDD (Table 36-1). Although the DSM-IV definition of PMDD specifies that this is not just an exacerbation of another disorder, the dividing line between PMDD and other neuropsychiatric disorders is not so clear cut. For example, 46% of PMDD patients have a history of a prior major depressive episode. Moreover, patients with PMDD and clinical depression share similar sleep electroencephalogram alterations, and they are both responsive to the selective serotonin reuptake inhibitor (SSRI) antidepressants.

TABLE 36-1 CRITERIA FOR PREMENSTRUAL DYSPHORIC DISORDER

Although PMS and PMDD patients and controls do not differ in their average cyclic levels of sex steroids, gonadotropins, prolactin, or cortisol, there exists a strong basis to believe that these disorders have a hormonal rather than purely psychologic basis.

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